Community-Led Support Services & Connections to Health Services: An Approach to Reduced Food Insecurity and Diabetes Diagnoses for Black/African American and Hispanic/Latino Populations - The mission of Jewish Family Service of Dallas, Inc. (JFS) is to provide effective and accessible whole-person care that promotes lifelong self-sufficiency and well-being for the North Texas community. The proposed project’s populations of focus will include Black/African American and Hispanic/Latino individuals who live in one of the following 13 ZIP codes: 75001, 75248, 75006, 75234, 75244, 75254, 75240, 75230, 75251, 75080, 75243, 75231 and 75238. Within the population of focus, the project will target low-income individuals who need access to healthcare. These populations were selected because of high rates of racial disparities prevalent in access to healthy food and transportation as well as high rates of food insecurity and diabetes diagnoses. JFS and the network partners expect to serve 7,047 clients over the four-year project period. The two social determinants of health (SDOH) domains the project will focus on are economic stability (SDOH 1) and health care access and quality (SDOH 2). A community level innovation is necessary to address the low rate of low-income individuals in the target area who should be served by a community health center who are actually receiving care from one. The project will make progress toward two leading health indicators (LHI): reducing household food insecurity or hunger (LHI 1) and reducing the number of diabetes cases diagnosed yearly (LHI 2). These LHI are related because individuals who experience food insecurity are more likely to develop type 2 diabetes (Centers for Disease Control and Prevention, Food and Nutrition Insecurity and Diabetes, 2022). By providing connections to healthcare for clinical screening for diabetes and access to nutritional support from food pantries and health education classes, the proposed project leverages the intersection of food insecurity and diabetes to address health disparities with multifaceted solutions. Using the Community Readiness Model, the goal of this project is to increase the use of preventive health services (SDOH 2) and improve economic stability (SDOH 1) among the target populations through community-based partnerships and wraparound care. The results of this would improve health knowledge and outcomes by reducing new diagnoses of diabetes (LHI 2) and by addressing health disparities that lead to food insecurity (LHI 1) and lack of access to transportation. For this project, JFS has secured letters of commitment from the following network members: Network of Community Ministries, Metrocrest Services and the Vickery Meadow Neighborhood Alliance. These members were selected because of their experience providing services that help individuals in the target area reach food security, which include food pantries, emergency financial assistance and financial and employment coaching. JFS will station community health workers (CHW) at its food pantry and health center and at network member locations to asses clients’ SDOH using the Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE) tool. To incentivize completion of the assessment, clients will be offered $20 grocery store gift cards. Incentives are designed to help remove barriers associated with completing forms to receive services. Based on client responses and needs, the CHW will connect clients to career, employment and financial coaching services; food pantry support; emergency financial assistance; health and financial education classes and preventative healthcare services provided by the network member that is the most geographically accessible to the client. As needed, clients will receive gift cards to rideshare providers and/or access to transportation by the JFS van driver. JFS will engage with a consultant for evaluation of program processes and outcomes in years two and four and will work with a writing consultant in year four to produce and publish a white paper that describes the project’s impact on health outcomes.
